J.B3H51 



THE 

UNIVERSITY OF MISSOURI 

BULLETIN 



Volume 15 Number 3 



MEDICAL SERIES 5 



THE RELATION OF SIGHT AND HEARING 
TO EARLY SCHOOL LIFE 



BY 

Guy L. Noyes 

Acting Dean of the Faculty of Medicine and Formerly 

Professor of Diseases of the Eye and Ear 

University of Missouri 




UNIVERSITY OF MISSOURI 

COLUMBIA, MISSOURI 

January 16, 1914 



MOD 



ograpii 



THE 

UNIVERSITY OF MISSOURI 

BULLETIN 



Volume 15 



Number 3 



MEDICAL SERIES 5 



THE RELATION OF SIGHT AND HEARING 
TO EARLY SCHOOL LIFE 



BY 

Guy L. Noyes 

Acting Dean of the Faculty of Medicine and Formerly 

Professor of Diseases of the Eye and Ear 

University of Missouri 




UNIVERSITY OF MISSOURI 

COLUMBIA, MISSOURI 

January 16, 1914 






OUTLINE OF CONTENTS 



Chapter 


I. 


Introduction. 


Chapter 


II. 


The Refraction of the Eye, its Errors and their Effect. 
Normal Refraction. 
Farsightedness. 
Nearsightedness. 
Astigmatism. 
Eye Strain. 

The Effects of Refractive Errors and Eye Strain 
upon Character. 


Chapter 


III. 


Troubles of Hearing. 

Adenoids in Their Relation to Hearing. 


Chapter 


IV. 


School Hygiene. 


Chapter 


V. 


The School Inspection. 
Outline and Record. 
Types and Times of Inspection. 
The Teehnic of Inspection. 
The Card of Warning. 



i2) 



THE RELATION OF SIGHT AND HEARING TO EARLY 
SCHOOL LIFE 

CHAPTER I 

INTRODUCTION 

The purpose of this bulletin is to present in nontechnical form some 
of the facts concerning visual and aural disturbances that are related to 
the early school life. That such relation does exist has long been known 
but the means of combating and controlling the evil results of the educa- 
tional process constitute one of the modern problems of preventive medi- 
cine. 

It is hoped that those who care to know just why a considerable per- 
centage of those who enter school in apparent good health soon manifest 
impairment of the chief organs of special sense will find a convincing ex- 
planation herein. Furthermore it is hoped that teachers and others hav- 
ing the desire to work in this problem of special hygiene may find some 
helpful suggestions as to the methodical prosecution of inspections of the 
eyes and ears of school children. No attempt has been made to discuss 
any of the problems of school hygiene other than those having to do with 
the functions of sight and hearing. 

The very elementary manner in which the refractive errors are de- 
scribed will, it is hoped, be excused by those familiar with physiological 
optics. The writer has thought best to proceed upon the assumption 
that the reader possesses no knowledge of optics, and that those desiring 
deep insight into the problems of physiological optics will naturally seek 
that elsewhere. 

To progress normally in school life and at the same time to retain 
health, become an active and intimate problem with every child entering 
school. The incidence of acquired disease of some of the organs of special 
sense and the process of education are known to bear a constant relation. 
That the educational process is responsible directly or indirectly for much 
physical suffering among children cannot be denied. In spite of much 
intelligent and well directed effort to improve conditions as to the housing 
and general hygiene of school children, the diseases of early life, and par- 
ticularly those closely associated with the eyes, continue to show them- 
selves. Moreover the proportion of children afflicted with defective 
vision increases as the children advance in the grades. 

It is plain that a child must gather his education, in school and out, 
largely as a result of activity of his special senses and especially of the 

(3) 



4 UNIVERSITY OF MISSOURI BULLETIN 

senses of sight and hearing. The rate of a child's progress in school de- 
pends very largely upon the accuracy and rapidity with which he can use 
his eyes. The requirements of the average school course are such as very 
promptly to bring into evidence the existence of eye defects. This is for 
the reason that from the very beginning of school life the eyes are caused 
to work excessively at the near point, or as is commonly said, for close 
work, such as reading and writing. The human eye is not naturally and 
normally adapted for doing sustained close work. 

The competition in school for relatively high standing is naturally 
keen, and is usually stimulated by school officers. As a result, the eyes, 
whether they be well fitted to stand the strain or not, are made to do work 
up to the limit of their possibilities, and, as a result, eyestrain promptly 
develops in a large number of children. With the early recognition of 
the signs of eyestrain and correction of the defects causing it, a child may 
continue through the educational process and emerge with both his edu- 
cation and eyesight. Failure to recognize the development of eyestrain 
and delay in correcting faulty reading habits and eye defects may deprive 
a child of his higher education, and also take from him for all time a large 
measure of his useful vision. 

In the majority of cases nature prints the danger signs plainly upon 
the countenance of the child, and if parent and teacher heed the warning, 
relief is quite certain. The danger signs are many and are often found 
in organs remote from the eyes. The protean symptoms that we recog- 
nize as due to the ordinary use of defective eyes or the excessive use of 
normal eyes we group under the term Asthenopia, or eyestrain. The 
recognition of eyestrain symptoms and the prompt institution of meas- 
ures to correct them are the two all important factors in the problem of 
school hygiene as it concerns the eyes. 

To the end that a better understanding may be had of the real nature 
of eyestrain, there follows an elementary explanation of the functioning 
of the normal eye as well as a comparative discussion of the abnormal 
conditions to which it is subject. 

The defects of form of the eyeballs which are primarily responsible 
for the development of eyestrain arc known as errors of refraction and are 
named: farsightedness or hyperopia; nearsightedness or myopia; and 
astigmatism. Of the three general types of error all have to do with 
departures from the normal either in shape or size of the eyeball. 

CHAPTER II 

THE REFRACTION OF THE EYE, ITS ERRORS AND THEIR EFFECT 

Normal Refraction. — The refraction of a normal eye is its power of so 
a '-ting on all the light rays that enter its pupil as to cause them to converge 
at one point inside the eye and on the retina. Clear and comfortable 
vision may be had only when all the light rays that enter an eye do con- 




SIGHT AND HEARING OF SCHOOL CHILDREN 5 

verge and meet at a point on the retina. All the powers of the eyes, nerv- 
ous and muscular, are concentrated on fulfilling this prerequisite for clear 
vision and as long as the powers are sufficient to accomplish it, as they are 
within reasonable limits in the normal eye, no trouble arises out of the use 
of the eyes. As soon as errors of refraction make clear vision difficult or 
impossible of accomplishment, pain, discomfort and disease are sure to 
follow, for the eyes still continue to strive after clear vision however diffi- 
cult or impossible the act may be. 

The normal eye is, of course, the standard eye. A normal eye is of 
such length as to receive all parallel rays of light at a focus upon its retina, 
while the eye is at rest (See Figure 1). It 
matters not in which meridian of the front 
of the normal eyeball the parallel rays enter 
the pupil, they will all be brought to a focus 
on the retina by means of the lens system 
that lies passively within the eye. The eye 
is said to be at rest when it is not actively 
focusing. The normal eye focuses for close 

FIG 1. THE NORMAL EYE. vigi(m Qnl {qj . j t nQ &Q% of f oeusing fe neeeS - 

(The letters H and V in this „ . . , . , 

and Figs. 2, 3 and 4 represent sary for purposes of clear distance seeing. 
rays passing through hor- The normal eye is supplied with appa- 

izontal and vertical meridians ra tus by which it can adapt itself for close- 
respectively.) vision. This apparatus is more or less auto- 
matic in its action. The adaptation for close work can be kept 
up continuously, within reasonable limits, without discomfort or 
harm to the normal eye. The power of the eyes to adapt themselves or 
focus for seeing at a varying distance is called Accommodation, and eyes in 
the process of accommodation are said to be accommodating. 

The normal eye then is one that is adapted for distance seeing without 
effort. The normal eye is one that accommodates for close vision only. 
The distance vision of the normal eye is taken as the standard of vision. 

For the purpose of having a clear understanding of the elements of 
eye refraction it is well to think of an eye as receiving upon its retina the 
image of every single object at which "it looks". The image on the retina 
is made by rays of light that proceed from the object looked at through 
the lens system of the eye, which focuses them on the retina. The image 
in the eye is plain or indistinct, depending upon the uniformity and accu- 
racy with which the rays meet upon the retina. The entering rays may all 
meet on the retina, behind the retina, in front of the retina, or part of them 
may meet in front and part behind the retina. Clear vision results only 
when all the entering rays finally meet at one point and that point is on 
the retina. By reason of certain natural laws, all rays of light coming 
from distant objects enter the eye as parallel rays. Immediately after 
these parallel rays enter the eye they are gradually bent from their condi- 
tion of parallelism to a condition of convergence. In the normal eye this 
bending affects all rays uniformly and is just sufficient in degree to gather 
them all very accurately at one point or focus on the retina (Figurel). 



6 UNIVERSITY OF MISSOURI BULLETIN 

This outlines the mechanism of all normal distance seeing. It is at- 
tended by the expenditure of no muscular energy, or accommodation. 

Unlike those coming from distant objects, the rays of light coming 
from near objects are divergent when they reach the eye. They proceed 
to and enter the eye as divergent rays. Immediately upon entering the 
eye, these rays are bent first from their condition of divergence to one of 
parallelism, and then from parallelism to convergence of just sufficient 
degree to bring all of them to an accurate focus at one point on the retina. 
This bending of all the entering rays of light so that. they may focus on 
the retina is the prime function of the transparent inside of the eyeball 
and is known as its refractive power. 

The refractive power of the eye is of two kinds: passive and active. 

The passive refraction is always effective and is never suspended 
nor augmented. It is not controlled by the will and remains a fixed, un- 
changeable quantity in a given eye. It is the passive refraction that, in 
the normal eye, brings all the entering parallel rays of light to a focus on 
the retina. Likewise it is the passive refraction that acts in the same fixed 
degree upon divergent rays that enter the eye, tending to make them less 
divergent. The passive refraction may of itself bring divergent rays to a 
condition of parallelism or even of convergence, if the rays are not too 
divergent upon their entrance. In the normal eye the passive refraction 
is never sufficient finally to bring divergent entering rays to a considerable 
enough convergence to cause them to meet at a point on the retina. In 
other words, the passive refraction cannot of itself give clear close vision 
to the normal eye. To do that more ray-bending power is needed than 
that which the passive refraction can supply. When the passive refrac- 
tion has accomplished all that it can, then the active refraction is promptly 
and automatically brought into play in just sufficient degree in the normal 
eye to bring all the entering rays of light together at one point on the 
retina. 

The active refraction is unlike the passive refraction in that the former 
is changeable and is used in varying degrees sufficient always to enable 
the eye to see clearly that close object at which it looks. The active re- 
fraction is never used by the normal eye save for purposes of close vision. 
In some abnormal conditions of refraction the active refraction is made use 
for distance seeing. Whenever for any reason the passive refraction is 
insufficient, the active refraction may be made use of to accomplish the 
perfect focusing. Such is the case in farsightedness. 

The active refraction of the eye is its power of accommodation, and 
the process through which it is accomplished is known as the accommoda- 
tion of the eye. The accommodation of the eye is its power to adapt 
itself for distinct seeing at varying distances. The accommodation may 
be brought truly under the control of one's will, but it acts, as a rule, with 
the greatest accuracy in a purely automatic way. The accommodation 
is made use of in widely varying degrees. It is used in increasing degree 
as the objects at which one looks approach the eye. The effort to see 
becomes progressively greater the nearer the object at which we look 



SIGHT AND HEARING OF SCHOOL CHILDREN / 

approaches the eye. At such continuous tasks as reading, writing, sew- 
ing, etc., the accommodation is used at its maximum. 

To recapitulate then, the normal eye sees all distant objects clearly 
without accommodation. This it does because all distant objects send 
parallel rays of light to the eye and the passive refraction of the normal 
eye is sufficient to bring all parallel rays together at a focus on the retina. 
In other words, the normal eye is in a condition, when at rest, to receive 
parallel rays of light at a focus on its retina. The normal eye sees close 
objects clearly by the use of its accommodation or active refraction. All 
near objects send divergent rays of light to the eye and the passive refrac- 
tion cannot possibly bend them to a sufficient degree of convergence to 
make them meet on the retina. If only the passive refraction were used 
they would gather at a point behind the retina. This would not fulfill 
the necessary conditions for the production of clear vision. Here the 
accommodation is brought into use. It exerts itself upon the insufficiently 
convergent rays and makes them all convergent enough to meet at a point 
on the retina. The conditions necessary for clear vision have been sup- 
plied by the accommodation and the eye "sees" the close object clearly. 
The accommodation power is made use of by the normal eye in all such 
acts as reading, writing, sewing, etc., etc. It is a perfectly normal process 
when used simply for purposes of close vision by the normal eye. 

Farsightedness. — The farsighted eye is shorter than the normal eye. 
It is so short that the point of focusing of parallel rays is always behind 

the retina while the eye is at rest (see Fig- 
ure 2). The farsighted eye accommodates 
both for distance vision and near vision. 
The farsighted eye then is not adapted for 
seeing at any distance far or near, without 
effort of accommodation. The farsighted 
eye is supplied with the same kind of auto- 
matic focusing apparatus as the normal eye. 
Unlike the normal eye the short one 

FIG. 2. THE FARSIGHTED makes use of gome of j ts focusing power 

(accommodation) for distant seeing. This 
is abnormal and in the economy of nature no adequate provision has been 
made for such demands as are thus thrown upon the muscles of accommo- 
dation. Normally this power is held in reserve for purposes of close vision. 
The accommodation has certain very definite limitations in range or power 
and since the short eye uses some of its accommodation for distance seeing, 
it has just that much less in reserve for purposes of reading. Read- 
ing or any close work then is accomplished by the highly farsighted eye 
under the greatest of difficulties. The reserve power of the eyes is soon 
exhausted and fatigue and eyestrain follow. The distance vision in the 
farsighted eye is good except in conditions of very high farsightedness. 
Twenty per cent of all eyes coming under test are farsighted. 

Farsightedness may be corrected by the use of glasses. The defect 
in form is not overcome or cured by the use of glasses. Proper glasses 




8 UNIVERSITY OF MISSOURI BULLETIN 

neutralize the defect in form as long as they are worn. The purpose of 
correcting glasses in hyperopia is to create a normal condition of refrac- 
tion for distance seeing. To do this the correcting lens must be just 
strong enough to act upon entering (parallel) rays of light in sufficient 
degree to allow them to focus on the retina of the hyperopia eye when it 
is at rest, i. e. using only its passive refraction. By this means glasses 
overcome the symptoms of eyestrain produced by farsightedness. 

In the majority of farsighted persons glasses do not improve the dis- 
tance vision, in fact blurring of distant objects is common when glasses 
are first worn to correct farsightedness. Such blurring soon disappears 
when the proper glasses are worn continuously. 

A plus spherical, or magnifying, lens is used to correct simple hypero- 
pia. The glasses are prescribed in the case of farsightedness not neces- 
sarily to make one see better but to make him see comfortably. Glasses 
are necessary, not because the patient has farsightedness but because his 
farsightedness is making eye strain that must be cured. Glasses used for 
the correction of eye strain dependent upon farsightedness may be worn 
all the time or only for close work. They should be worn enough to cause 
all symptoms of eye strain to subside. It sometimes happens that a school 
child may properly discontinue the use of glasses after having worn them 
a year or more. 

In the early years of life farsightedness shows a tendency to decrease. 
This tendency may be marked enough so that in the first few years of school 
life eyes previously farsighted may gradually become nearsighted. 

Nearsightedness. — Myopia or nearsightedness is that condition of 
abnormal shape or form in which the eyeball is too long. In this respect 
the condition is the exact opposite of farsightedness. 

The nearsighted eye in the majority of instances is a diseased eye and 
unless precautionary measures are adopted early in life, the nearsighted 
eye will automatically become more and more 
nearsighted and more diseased until finally at 
midlife a large portion of the acute seeing 
power will be gone beyond recall. 

The nearsighted eye is one that, while at 
rest, receives parallel rays of light at a focus 
in front of its retina. (Figure 3). It follows 
therefore, that since parallel rays come to 
fig. 3 the near- the eyes from distant objects, the nearsighted 

SIC HTFD pyp 

eye sees nothing clearly in the distance. Nor 
can it by use of its accommodation adapt itself for clear distance seeing. 

The nearsighted eye is one that is in condition to receive divergent 
rays at a focus on its retina. Divergent rays, as we have seen, do exist 
in nature and are emitted from all objects that happen to be situated less 
than twenty feet from us. The myopic eye is in a condition then to see 
some close objects clearly without effort of accommodation. 

Unfortunately there exists no power within the nearsighted eye that 
enables it to correct automatically its faulty refraction. The use of the 




SIGHT AND HEARING OF SCHOOL CHILDREN 9 

accommodation could never under any condition improve the distance 
vision of a myopic eye. As children ascend through the school grades the 
proportion of myopia to other defects gradually increases. In the very 
beginning of school life about two per cent of children have myopia while 
of those of late high school or early college life thirty per cent have myopia. 
\y_ Moreover nearsightedness by its very nature provides for its own 
increase and when untreated and uncorrected by glasses, its tendency 
is to increase constantly in degree. Progressive increase in degree of near- 
sightedness means constantly increasing elongation of the eyeball. Elonga- 
tion becomes so great that the delicately organized tissues of the inside 
of the eyeball can no longer adapt themselves to the stretching process 
and they are finally ruptured, with very disastrous results to vision. 

Early and proper correction of myopia by glasses will usually stop 
its further progress. The correcting glass in myopia must so act upon all 
rays of light that enter the eye as to delay their focusing until they have 
passed through the long eyeball and reached the retina. A minus spher- 
ical or minifying glass corrects myopia. 

Correcting glasses are prescribed in myopia to give clear and comforta- 
ble vision. No rule may be given for the use of glasses in myopia. Some 
myopes need glasses all the time and some use them only for distance 
seeing. Nearsightedness is usually associated with more or less astigma- 
tism. 

The accommodative function of the eye, so useful in the automatic 
neutralization of farsightedness, so far as excessive use is concerned, plays 
no part in the eyestrain associated with nearsightedness. In myopia, 
however, the discomfort of eyestrain may be as considerable as in hypero- 
pia and the involvement of the seeing power is even greater. The eye- 
strain symptoms in nearsightedness may be in the main the same as those 
accompanying farsightedness. The distance vision is always lowered in 
myopia. Nearsightedness should be considered as a disease and sufferers 
from neglected nearsightedness must confidently expect to lose more or 
less of the usefulness of their eyes as time passes. The permanent loss 
of vision in myopia is as a rule commensurate with the amount of near- 
sightedness. 

While the distance vision in nearsightedness is always lower than 
normal it can be brought up to normal by proper correcting glasses, if no 
disease exists in the eye. 

Astigmatism. — The third of the changes in the shape of the eyeball 
which are classed as refractive errors is astigmatism. Of all eyes subjected 
to careful examination sixty-five per cent have some form of astigmatism. 
This does not include that small and inconsequential astigmatism that 
we call normal because it exists in all eyes. The normal astigmatism is" 
that which makes stars in the sky appear to have an irregular outline. 
Normal astigmatism does not give rise to eyestrain. 

In astigmatism the defect is not one necessarily involving length of 
the eyeball. Normally all light rays entering the eye are bent to a com- 




10 UNIVERSITY OF MISSOURI BULLETIN 

mon focus on the retina. This bending 
process is begun by the cornea which 
normally bends all the light rays that 
pass through it in equal degree. In 
astigmatism the cornea bends all the 
rays but does not bend them equally, and 
as a result the rays that pass through one 
meridian are brought to a focus before 
those passing through other meridians. 
fig. 4 the astigmatic eye ^ happens that as a rule the rays passing 

through the vertical corneal meridian of 
an astigmatic eye come to a focus before those passing through the horizon- 
tal corneal meridian. Such a condition of astigmatism is shown in Figure 4. 
The defect in astigmatism lies in the cornea or in the lens, more often 
the former, sometimes in both. The nature of the defect is a change in 
the curvature or in the refractive index of either the cornea or lens. In- 
stead of being evenly curved in all meridians like an ordinary sphere, the 
surfaces of the cornea or lens partake in small degree of the shape of the side 
of an egg, i. e., curved more in one meridian than all the others. This unequal 
curvature of the surfaces through which light rays must pass to reach the 
retina makes an accurate focusing of the rays impossible and consequently 
makes clear and distinct vision impossible. No power lies within the astig- 
matic eye automatically to correct such faulty focusing. The exercise of the 
accommodation can give no clearer vision to the astigmatic eye, for the 
accommodation affects all rays in equal degree. The astigmatic eye con- 
tinues to strive for clear vision however, and this continual strife for the 
unattainable creates eyestrain of the very worst and most aggravated 
type. Sufferers from astigmatism may have all the most acutely painful 
and generally disturbing symptoms of eyestrain. 

Astigmatism is usually found to be present in combination with either 
nearsightedness or farsightedness. The most common error of refraction 
is that in which astigmatism and hyperopia are combined. That this is 
unfortunate is plain when one considers that all the disturbing symptoms 
of astigmatism are, under such conditions, simply superimposed upon 
those of hyperopia. 

No symptom is necessarily characteristic of astigmatism, but it does 
usually greatly intensify the symptoms of eyestrain. It is astigmatism 
as a rule, and sometimes only the very smallest degree of it, that creates 
the reflex nervous symptoms of eyestrain. Such are the symptoms of 
eyestrain that are found in regions remote from the eyes and at first sight 
having no apparent relation to the eye. The limits of the body alone limit 
the remoteness at which reflex symptoms of eyestrain may develop when 
caused by astigmatism. 

Like myopia and hyperopia, astigmatism may be corrected by glasses. 
The lens which will correct this refractive error is known as a cylindrical 
^ens. Its action may be either magnifying or minifying. It is peculiar 



SIGHT AND HEARING OP SCHOOL CHILDREN 11 

in that it refracts rays of light in all of its meridians save one. Rays of 
light that pass through the axis of a cylindrical lens are not refracted at all. 
A little thought and reference to Figure 4 will show the usefulness of cylin- 
drical lenses in the correction of astigmatism. 

Eyestrain. — Under the term "eyestrain" we assemble that group of 
unnatural symptoms and signs that follow the use of the eyes for close 
work. The evidences of eyestrain may develop in those who have no real 
defect in form of the eyes. Under such conditions the eyestrain is caused 
by the faulty use of a relatively normal organ. Eyestrain is usually due 
to some defect of form, i. e., some refractive error. Technically, 
eye strain is spoken of as Asthenopia, which means weak eyes. It is 
well to keep in mind that weak, in this connection, means lacking 
in strength. There is a popular belief that a weak eye is a tearing 
eye, but such need not necessarily be the case. Tearing may be the re- 
sult of conditions having absolutely nothing to do with eyestrain or the 
act of seeing. 

There are three general groups of eyestrain symptoms referable to 
the eyes themselves. 

1. Accommodative. — 

This group is due to abnormal demands upon the focusing muscle 
of the eye. This type is no doubt most commonly associated with hypero- 
pia. 

2. Muscular. — ■ 

This group is due to imbalance in the relative strength of the muscles 
that move the eyeballs in their sockets. Asthenopia of this form may 
result from one kind of refractive error as well as another. 

3. Nervous and Retinal. — 

This group is due to unusual irritability and sensitiveness of the retina 
or nervous coat of the eye. Astigmatism, more than the other errors of 
refraction, is responsible for this form of asthenopia. 

All types of asthenopia are due primarily to some abnormality in the 
refraction of the eyes. Eyestrain shows itself by certain quite constant 
signs and symptoms. With experience in the observation of such condi- 
tions we soon come to look upon certain groups of signs and symptoms 
as positive evidence of eyestrain and upon other groups as presumptive 
evidence. Indeed there are those evidences of eyestrain that, existing 
alone, might be classified as doubtful, but when found in combination 
with positive signs become themselves of positive significance. There 
are a large number of eyestrain symptoms the manifestations of which 
are anatomically more or less remote from the eyes. Such symptoms are 
often so distressing as to make a condition of practical invalidism. Ex- 
cept to the skilled observer, the symptoms in this group may not attract 
attention, as a part of a condition of or the result of eyestrain, because of 
their very remote location in the body in relation to the eyes. A persistent 
pain in the back of the neck for instance, or indeed a condition of serious 
indigestion or lateral curvature of the spine may be due solely or primarily 



12 UNIVERSITY OF MISSOURI BULLETIN 

to eyestrain. One such symptom should not be looked upon as sufficient 
to make certain the diagnosis of eyestrain. With intelligent questioning 
it is almost always easy to elicit from the sufferer from eyestrain the fact 
of the existence of many positive symptoms. The conclusive and usually 
easily determined fact is that the group of symptoms indicating eyestrain 
usually develops after the use of the eyes in reading, writing, and other 
acts requiring the use of the eyes at arm 's length. It is true that eyestrain 
may be in evidence without relation to the use of the eyes for close work. 
The symptoms may bear a constant relation to the use of one's eyes dur- 
ing his waking hours. 

Certain eystrain sufferers find their symptoms to be associated with 
theatre going or attendance in other brightly lighted places. A long drive 
or a ride in a railroad train may also precipitate an attack of eyestrain. 
In the latter case one is said to be car-sick. People have been known to 
suffer for years from car-sickness only to find by accident that correction 
of hyperopia or astigmatism by glasses caused the car -sickness to disap- 
pear altogether. 

There follows a list of the common signs and symptoms of eyestrain. 

Rapid fatigue of eyes during reading, writing, etc; headache; sick 
headache; pain in the eyes; blurring of print; feeling of sand in eyes; pain 
in the back of ^he neck and between shoulders; difficulty in fixing atten- 
tion or concentrating one's mind on reading matter; tendency to rub and 
press on the eyeballs; redness of the edges of the lids; accumulation of 
branlike masses on the edges of the lids; double vision; dread of light; 
dizziness; cross eye; nausea; floating spots before eyes; tearing; car-sick- 
ness; blindness in one eye; various neuralgias; brain fag; drowsiness; 
twitching of the lids; a tendency to the development of stys in "crops"; 
many serious, destructive, and inflammatory conditions affecting all of 
the tissues of the eyeball. 

Some of the remote reflex nervous evidences of eyestrain are, serious 
disturbances of the digestive tract, and even of the brain and spinal cord. 
They may lead to St. Vitus 's dance, epilepsy, lateral spinal curvature, 
nervous breakdown, criminality and truancy. 

It should be remembered that no absolutely constant relation exists 
between the degree of eye defect and the intensity of eyestrain symptoms. 
Relatively small defects may cause most severe symptoms, and large 
errors may pass for years unnoticed. Conditions of general ill health 
bring eyestrain symptoms into prominence and so does constant close 
work. The person who does no reading or writing or other close work is 
not apt to show the symptoms of eyestrain even if his eyes are defectively 
formed. The symptoms of eyestrain seldom result from use of the nor- 
mal eye. They do come quickly from the ordinary use of the defectively 
formed eye. The defect may be ever so small and yet the resulting symp- 
toms may be overwhelming. On the other hand, it is true that the dis- 
eased processes almost constantly associated with nearsightedness may 
progress to the point of destroying a large measure of sight without a 
single painful symptom. 



SIGHT AND HEARING OF SCHOOL CHILDREN 13 

The best way to conserve the eyesight and prevent the diseases asso- 
ciated with eyestrain is to correct, especially in early school life, all errors 
in the formation of the eyes by means of glasses. Nothing short of the 
most skilful examination and most careful and accurate adjustment of 
glasses is adequate to meet the conditions that actually exist in a 
case of ordinary eyestrain. The present day demands upon the eyes, 
so far as the educational process is concerned, are entirely in excess of the 
normal latent and inherent ability of the eyes to perform. The average 
eye is not so constructed as naturally to adapt it to the doing of close 
work for long periods of time. As a necessary consequence, the symptoms 
of faulty function, or eyestrain, are commonly in evidence soon after the 
beginning of school life. Since the eyes are not equal to the work that 
they are called upon to do, no surprise ought to exist as to the increasing 
need for glasses and their use. The only means by which the insufficiently 
adapted organ may be artificially adapted to do that which is required of 
it without damage and disease is by the use of spectacle lenses. 

The act of distance seeing should be an absolutely passive process and, 
after the eyes have once been directed toward an object, seeing should be 
carried out with as little expenditure of bodily energy as the process by 
which the ear perceives ordinary sounds or that by which the forms of 
objects are communicated by the sense of touch. This ideal condition 
exists in the normal eye. It does not and cannot exist in eyes with refrac- 
tive errors. In such eyes all clear and distinct distance seeing is accom- 
plished only by a positive muscular and nervous effort, unconscious though 
it may be. Since no adequate provision is made by nature for this extra- 
ordinary effort the symptoms of fatigue soon appear. The act of close 
seeing as in reading, writing, etc., makes even greater demands upon the 
muscular and nervous energies. 

The Effects of Eyestrain and Refractive Errors Upon Character. — 
That farsightedness, nearsightedness, and astigmatism do influence one's 
habits of life in characteristic ways is certain. 

Aside from the primary evidences of mere eyestrain common to all 
the types of refractive error, there soon shows itself, in some pupils, a cer- 
tain habit of mind that we associate with nearsightedness. It should be 
recalled that the zone of perfect vision in nearsightedness is always less 
extensive than in the normal condition of sight. With an increasing 
degree of nearsightedness the zone becomes more and more restricted until, 
in what might be called a moderate degree of nearsightedness, a child may 
see nothing clearly and distinctly beyond the length of his arm. Having 
had no experience with normal seeing the child with poor vision assumes 
that he sees as well as others, indeed, he often insists that he can see very 
well and as well as his companions and schoolmates. As a matter of fact 
he sees well and with distinctness to the minutest degree of detail the things 
within his limited zone of vision. He has never seen trees in blossom or 
in full leaf as the normal child does. His zone of distinct vision has been 
restricted until he can touch with his forefinger, as it were, any point in 
the whole circumference of his own visible horizon. 



14 UNIVERSITY OF MISSOURI BULLETIN 

It falls to the lot of every oculist to witness the expressed joy of the 
nearsighted child of grade school age who, after having been given his first 
pair of glasses, sees clearly across the street, and, for the first time in his life, 
gets a glimpse of distant scenery with its hills, dales, trees and homes 
which have been to him previously unknown, in the composite visual 
sense. 

By reason of this very restricted zone of vision a nearsighted school 
child without glasses gradually loses interest in games and sports that re- 
quire good distance seeing. His interests are confined to such things as 
can be clearly seen by him. He develops easily the studious habit and 
becomes a leader in his classes. His success as a student brings forth the 
encouragement and approbation of his teachers and elders. This he nat- 
urally enjoys and in the stress of competition he clings to the work that 
he does successfully and abandons entirely the normal out of door sports 
and life. 

A tardy school inspection, the serious disease of his eyes, — directly 
due to his excessive study, or a mere accident, may be the cause of his 
first information concerning the real condition of his eyes. At ten or twelve 
years the information may have come too late. All the terrible ruin of 
progressive nearsightedness may have consumed the delicate retinal ele- 
ments in sufficient degree to have destroyed a measure of vision beyond 
all hope of cure or neutralization by glasses. All this may have come 
about without a single painful symptom. The inflammatory disease 
of the vital, vision giving structures of the eyes is the direct result of near- 
sightedness, sooner or later, in seventy-five per cent of all eyes affected 
by nearsightedness. 

Destructive and progressive nearsightedness is a natural concomitant 
of school life and of the life of the essential eye user. Nearsightedness 
increases and its complications develop in early school life in spite of the 
most intelligent attention to the general principles of school hygiene as 
to school architecture, furnishings, light, ventilation, etc. The only 
means by which this ruinous condition may be controlled in any degree 
are by correcting promptly with glasses any error of a nearsighted nature 
and restricting the amount of close work to be done. Unlike the other 
refractive errors, nearsightedness by its very nature provides for its own 
increase, and the only way to arrest the progress of the defect is by prompt 
change and adjustment in the correcting glasses in accordance with the 
advice of an oculist. The proper management of the nearsighted child 
in school, so far as the eyes are concerned, calls for all of the intelligence 
and skill of the most accomplished oculist. The early discovery and cor- 
rection of nearsightedness then will tend to check its further development. 
Early correction of nearsightedness restores normal distance vision and 
allows a child the opportunity for development of all those out of door 
interests which we look upon as normal in a child and which are automat- 
ically withheld from the child with uncorrected nearsightedness. 

So far as the influence upon the general intellectual development is 
concerned, farsightedness and astigmatism may be considered as one con- 



SIGHT AND HEARING OF SCHOOL CHILDREN 15 

dition. As a matter of fact the combined errors of farsightedness and 
astigmatism furnish by far the most common type of refractive error. 
When the farsightedness predominates and the astigmatism exists in small 
degree the distance vision may be very good. Conditions of farsighted- 
ness and astigmatism work their untoward influence upon the develop- 
ment of character not by reason of lowering the vision but because of the 
discomfort that they cause during the use of the eyes. Small degrees of 
astigmatism always lessen in some degree the acuity of vision, though not 
by any means to the same degree as nearsightedness. As has been men- 
tioned previously, clear and distinct vision either for distant or near points 
is obtainable by the farsighted eye only by the expenditure of a definite 
but unconscious muscular effort. This effort is not required of the normal 
eye and no adequate muscular or nervous provision has been made by na- 
ture to furnish this excess of energy for the farsighted eye. The farsighted 
and astigmatic eye works under an overload during all of of one's waking 
hours. Persistence in close work under such conditions results in an over- 
draft on the visual apparatus and the consequent development of eyestrain 
and its train of discomforts and lessened ocular efficiency. 

In the case of a child in early school life it is plain then that, if he suf- 
fers from any considerable amount of farsightedness or astigmatism, no 
pleasurable reaction can come from efforts to study. His power of mental 
concentration is soon overcome, dominated and submerged as it were, by 
intensely disagreeable sensations the source of which he in his inexperience 
cannot locate. He has blurring perhaps, but cannot describe it or does 
not realize that he sees less distinctly than other children. He does soon 
learn to associate intimately his school tasks requiring the use of his eyes 
with certain very uncomfortable sensations such perhaps as headache, 
eyeache, backache, mental confusion, drowsiness, nausea, dizziness, 
double vision, etc. He recognizes that he is relatively comfortable 
before and after school, and he naturally associates his pleasurable sensa- 
tions with out of door activities. The gaining of knowledge by means of 
his visual organs in school provokes only painful sensations and he shuns 
study. He is interested in sports and shows normal or maybe more than 
normal prowess, both physical and mental, in the activities that do not 
require the use of the eyes for close work. In the competition of the school 
room for grades, he falls behind his fellows and finds himself discredited 
at home and in school. The unhappy child may have very acute vision 
and be unable to associate cause and effect in his difficulty. He cannot 
whip his eyes into submission, they dominate and call him away from 
eye work to the restful open out of doors. The road to truancy is short 
and easy from this point. 

Many such a farsighted pupil of tender years is unfairly adjudged 
vicious and is chastised at school and at home. Whether the chastise- 
ment take the form of physical or mental degradation, the net result is the 
same. The child learns to hate the school, its methods, and all those 
who personify it. The remedy is clear to see and easy of accomplishment. 



16 UNIVERSITY OF MISSOURI BULLETIN 

Teachers in public schools should be so trained that they may quickly 
recognize the early signs of eyestrain as shown in otherwise apparently 
healthy and vigorous youngsters. To the everlasting credit of the teach- 
ing profession let it be said that teachers are intelligently alert to this 
problem as a rule and that parents stand in the way of the correct man- 
agement of the problems of ocular school hygiene far more frequently 
than do teachers. 

Rigid, repeated eye inspections in the schools will surely save the 
eyestrain sufferer from the sorrows which he innocently bears. The 
correct determination of the kind and amount of refractive error and its 
accurate correction by means of glasses will prevent blindness, suffering 
and failure in early school life which is the portion of a pitifully large 
percentage of those who enter school. Moreover, it appears plain that if 
certain children begin the educational process with eyes essentially un- 
fitted for close work of long duration and, furthermore, if the educational 
process itself tends to increase this ocular disablement, our duty is to 
advise the pupil against a career of such nature as to demand the excessive 
use of the eyes. Preparation for the practice of all the professions contem- 
plates really excessive use of the eyes. Insistence upon a greatly modified 
curriculum and lengthening the number of years of school life furnish 
the only means, in addition to skillful correction of defects, of making it 
at all safe for the nearsighted child to attempt to prepare himself for a 
career as an essential eye user. 

CHAPTER III 

TROUBLES OF HEARING 

The eye troubles just considered may fairly be looked upon as being 
caused in large degree by the educational process itself. This of course 
does not apply to diseased throat and ear conditions except as they are 
favored by faultily constructed and managed school houses. It so hap- 
pens that the years of childhood are those in which the common ear and 
throat conditions here considered frequently occur. It follows then that 
throat and ear diseases and their complications are responsible for a large 
part of the absences from school of young children. 

Of all the organs of special sense.the ears are the ones most neglected 
even after their function has become notably impaired. Repeated re- 
curring attacks of ear trouble with great pain and discharge (risings) are 
looked upon by many parents as unavoidable misfortunes to be dreaded 
but not to be considered as serious even so far as the function of hearing 
is concerned. The condition of chronic discharging ear is the cause of 
forty per cent of all cases of abscess of the brain. 

It is well to remember that a "running ear" acquired possibly by neg- 
lect during childhood will prevent its possessor from obtaining first class 
life insurance in adult life. As a matter of fact every single attack of mid- 
dle ear inflammation (earache) leaves its mark upon the ear tissues and 



SIGHT AND HEARING OF SCHOOL CHILDREN 17 

reduces in greater or less degree the power of hearing. The condition 
ordinarily spoken of as earache, whether followed by discharge from the 
ear canal or not, is due usually to the presence of adenoids either enlarged 
or diseased. Earache should be looked upon as one of the symptoms of 
a very serious ear disease, serious always as to its effect upon the hearing 
and sometimes even serious as to life itself. A running ear should always 
be treated by an ear doctor; it will not get well without good care. Chil- 
dren do not "outgrow" running ears. 

It so happens that few, if any, organs in the human body can fall so 
far below the normal in the performance of their function as the ears, 
without the defect being noted. The sum total of normal hearing is much 
in excess of that actually necessary for daily contact in school. An un- 
noticed deficiency in hearing may even include the total loss of hearing 
of one ear. Practically all the ear troubles noted in early school life may 
be controlled and recurrent attacks may be prevented by prompt attention 
at the hands of an aurist. When deafness is so marked as to be detected 
easily by the unskilled observer, the opportunity to do the greatest 
good by treatment has gone. Repeated examinations, two or three in 
each school year, are necessary if the greatest good is to be achieved. 

Faulty habits of cleansing the ear canal may lead to disease of the ear. 
A moist cloth applied on the finger is the only object that one should put 
in his ear for the purpose of cleansing it. The custom of using earspoons, 
hair pins, pens and other metallic objects in efforts to dislodge wax from 
the ear is a very dangerous one and has led to very serious consequences. 
If the ears need cleaning further than can be accomplished by the means 
indicated above, a doctor should advise it or carry it out himself. A con- 
siderable quantity of loose wax is normally found in the ear canal and 
does no harm there. 

Children known to have chronic discharging ears should not be al- 
lowed to "dive" while bathing. Vigorous blowing of the nose to the point 
of making the ears "pop" is dangerous. Children should be taught to 
blow the nose in the loosely held handkerchief without pressing one side 
of the nose. Much ear trouble may be avoided by so doing. 

Adenoids in their Relation to Hearing. — With the exception of eye- 
strain, the most important common affliction of school children is nasal 
obstruction. The nasal obstruction due primarily to swelling of the 
structures within the nose itself is not common except in the case of ordi- 
nary "cold in the head". The nasal obstruction due to enlargement of 
the pharyngeal adenoid, a structure in the very back part of the nasal 
cavity, is common and very disastrous if allowed to continue. Mouth 
breathing and all its direct consequences are promptly evident results 
of enlarged adenoids. Ear symptoms also are very prominent. 

The word "adenoid" has come generally to mean that mass of tissue 
lying normalty in the very uppermost part of the throat where that cavity 
communicates with the back part of the cavity of the nose. It is in this 
sense that the word is used here. The ear and throat troubles of children 



18 UNIVERSITY OF MISSOURI BULLETIN 

of school age are for the most part due to the presence of abnormal ton- 
silar or adenoid tissue, one or both. The adenoid and tonsils are normal 
tissues and are found in every individual. These tissues depart from the 
normal in three ways: They may be diseased or they may be enlarged 
or they may be both diseased and enlarged. 

Disease may be present in great degree without much apparent en- 
largement. There is a well recognized condition in which the tonsil is 
much enlarged but hidden from view as the throat is ordinarily seen by 
simple inspection. The judgment of the average individual as to the size 
of the tonsil or as to the extent of disease in a tonsil is quite worthless and 
such judgments to be of value must be made by the physician. The usual 
external evidences of enlarged tonsils and adenoids are so characteristic 
that no skilled observation is required to determine their presence. 

The usual signs and symptoms of either enlarged tonsils or adenoids 
or both together are: mouth breathing with snoring or very loud breathing 
during sleep; the mouth breathing soon causes a characteristically fixed 
and expressionless countenance; the child appears of low mental caliber, 
takes cold easily, and has "snuffles" almost continuously. Earache is 
common. 

The bony framework of the face undergoes abnormal changes such 
as retraction of the lower jaw and narrowing of the dental arch. The 
whole mental and physical development of a child may be heavily handi- 
capped by this condition to the degree often of making a child of distinctly 
low mentality and of causing every appearance of critical arrest of develop- 
ment with poor nutrition. Disregard of the signs of nasal obstruction 
in early life may not only fix for all time the unfortunate abnormalities 
of face and frame, but may also make way for a train of abnormal condi- 
tions known generally as rheumatism and heart trouble. Indeed severe 
attacks of tonsilitis are often followed by Bright 's disease, inflammation 
of the joints, and of the lining and covering of the heart. 

The probability of occurrence of all these unfortunate things can be 
entirely overcome by giving proper consideration and attention to the 
early signs of enlarged adenoids and tonsils. Certain and complete re- 
lief lies in early operation for removal of the obstruction. By early opera- 
tion is meant operation as soon as symptoms of obstruction or disease 
develop. 

From six to twenty-five per cent of school children have nasal obstruc- 
tion in some degree. The wide margin between the six and twenty-five 
per cent is accounted for by the fact that the children of the poor are more 
apt to be affected than others. Increasing age and life under favorable 
conditions seem to lessen the occurrence of nasal obstruction. 

For the purpose of giving a better understanding of the symptoms 
arising out of enlarged and diseased adenoid tissue, it is well to classify 
some if not all of them in three general groups as follows : 

A. Obstructive symptoms: — Mouth breathing, periodic embarrass- 
ment in breathing and swallowing, noisy breathing (snoring) at night, 
"throaty" speech with strong nasal quality. 



SIGHT AND HEARING OF SCHOOL CHILDREN 19 

B. Catarrhal Symptoms: — Continuously recurring colds in the 
head, cough, asthma, and sore throat. 

C. Complicating Symptoms: — Imperfect facial development; irreg- 
ularity in eruption of the teeth; abnormal formation of the jaw bones; 
enlarged glands in the neck; fever; general nervous irritability^ ; malnu- 
trition as evidenced by pallor, emaciation, and skeletal deformity of chest; 
earache; deafness; acquired deaf -mutism; endocarditis (inflammation of 
the heart); arthritis (inflammation of the joints); twitching or spasm in 
the muscles of the face; mental dullness; tendency to "catch" infectious 
diseases easily. 

The symptoms here mentioned are not all that may be caused by nasal 
obstruction. Of course the mere schoolroom life is not directly responsible 
for the development of nasal obstruction except in so far as poorly ven- 
tilated rooms predispose to adenoid enlargement. One noted hygienist 
is quoted as having said recently that enlarged adenoids could be cured 
by a continued residence in the open air. This statement should not be 
considered as meaning that any one recommends such a procedure in the 
presence of symptoms as pronounced as those mentioned above. 

It so happens that all the acute infectious fevers and diseases of chil- 
dren characterized by fever and skin eruptions have a tendency to cause 
an increase in the size of all adenoid masses. Since children in early 
school life are particularly susceptible to the group of infectious fevers 
typified by measles, chicken pox, etc., it follows naturally that at about 
the ordinary age of early school life there is a tendency toward enlargement 
of adenoid tissues. It seems impossible that such prominent signs of 
disease as those here tabulated should escape notice in the homes of chil- 
dren. That they do escape notice or are disregarded is common knowl- 
edge. 

The school inspection with its card of warning and recommendation 
is very helpful to many timid parents as a moral bolster. All the pressure 
and influence of the school organization should be brought to bear to in- 
duce parents to seek medical advice and attention in the event of the dis- 
covery of nasal obstruction or its complications. Finally the physician 
must determine whether symptoms referable to the nose and throat are 
due to enlargement of the phalangeal adenoid or of the tonsils or of both. 
With enlarged tonsils the adenoid will always be found enlarged but en- 
largement of the adenoid may occur alone without abnormality in the 
tonsils. 

Mouth breathing once established may persist as a habit after the 
most thorough removal of the nasal obstruction. 

Tonsils and adenoids may safely be removed at any time of the year. 
The tendency to "take cold" is lessened rather than increased by opera- 
tions for removal of obstructions in the nose and throat. 



20 UNIVERSITY OF MISSOURI BULLETIN 

CHAPTER IV 
SCHOOL HYGIENE 

The age at which a child should go to school should be determined by 
his physical as well as by his mental condition. The child who shows any 
tendency toward nearsightedness or other eye defects should be protected 
against the regular educational process until repeated tests of his eyes 
show the defects to be under control and stationary. Attention to this 
detail will in the end assure to a child the utmost of success and celerity 
in the completion of his preparation for his life work. 

The investigation of Risley, Standish, Allport and others have enabled 
us to formulate certain fundamental rules concerning the building and 
lighting of school houses and the printing of schoolbooks. Briefly they 
are as follows: 

Window-space should be at least one square foot to every five of floor 
space. 

The nearest building should be twice as far away as its height. 

Light should fall on pupils' desks from the left and rear. 

No light should fall or be reflected directly into pupils' faces. 

No artificial light should be required in the ideal school room. 

North light is preferable but a proper arrangement of awnings and 
shades makes light from any direction available. , 

School rooms to conform to the ideal should have the following dimen- 
sions: 

Length 32 feet 

Width 24 feet . 

Height 15 feet 

Window space (linear measurement) 24 feet 

Height of window sills from floor 3 feet 

Height of windows 1 1 feet 

Such a room will accommodate forty-five pupils. 

All school furniture should be so arranged as to allow of ready adap- 
tation to the size of the individual pupil to the end that the normal erect 
sitting posture may be readily maintained. 

School books should be easily read and be light enough to be held 
easily in one hand. 

The type from which they are printed should not be smaller than 
ten point or long primer. 

The printed lines should be not more than four and one-half inches 
long. 

The lines should contain not more than sixty letters and should be 
at least one-tenth of an inch apart. 

The paper should be free from glazing so that no shine is apparent 
on its surface. 



SIGHT AND HEARING OF SCHOOL CHILDREN 21 

The playthings of kindergarten and primary schools should be large 
and never have on their surface small characters or figures at which young 
and tender eyes will be caused to look intently and continuously. 

Blackboards should never be situated between windows. They 
should invariably be of a dull black and not shiny. Characters written 
on them should be in a strongly contrasting color and in size sufficient to 
be seen easily by all pupils in a school room. 

One should never read in a dim light. Bright direct sunlight should 
be excluded from the eyes while reading. 

The best possible form of reading light is diffuse daylight, and arti- 
ficial light that resembles that most closely is to be desired. 

Of the three agents for producing artificial light, — electricity, gas, 
and kerosene, the latter probably makes the best light when proper burn- 
ers, lamps, and care can be provided. The inconvenience and odor and 
the difficulty in properly attending oil lamps makes their use impractical 
as a rule. Moreover they do produce too much heat and vitiate the air 
in the rooms in which they burn. Gas, when used with an incandescent 
mantle, produces a good white light but it develops too much heat and 
also vitiates the air in which it burns. All things considered electricity 
furnishes the best light when properly supplied. It can be supplied in 
steady volume uninfluenced by currents of air. It supplies the maximum 
of light with the minimum of heat. The naked loop of the electric bulb 
has properties that impair its usefulness as a reading light. All bulbs 
used for reading should be wholly or partly frosted. 

Eye work carried out under direct and semidirect systems of artificial 
illumination is attended by a rapid fall in ocular efficiency. The ideal 
system of artificial illumination is the indirect method by which no light 
falls directly upon the work but all of it is reflected from the walls and 
ceiling. Proper indirect artificial illumination is best obtained by elec- 
tricity. Professor Farree has shown that in doing continuous Avork by 
means of indirect illumination the loss of ocular efficiency is not much 
greater than with the use of diffuse daylight. 

Any hanging light that swings is unfit for use in reading. The arc- 
light, however modified, is unfit for purposes of reading. 

Children who read or otherwise use their eyes in school in great de- 
gree should not read at home during the school term. Body position, 
source of light, and degree of light are as apt to be disregarded at home as 
in the school room. Children should not read in any other than the erect 
sitting posture. Greek characters, German script, and the music staff 
and notes are particularly trying to the eyes of those who have astigma- 
tism. Music, Greek, and German should never be combined in the curric- 
ulum of one who suffers from eyestrain. The eyes should be rested at 
frequent intervals while reading. The best plan is to shift from one occu- 
pation to another for short periods of time. 

Printing that cannot be seen at twenty inches should not be read 
continuously at any distance. 



22 UNIVERSITY OF MISSOURI BULLETIN 

To read when one is drowsy is dangerous. 

Effort at reading through poorly adjusted glasses is damaging to the 
eyes. Reference is made here not so much to poorly adapted glass lenses 
as to ill-fitting frames. 

The use of unclean lenses is unwise. 

In the case of a child it is a good general rule to assume that if he 
needs glasses at all he needs them all the time and should be caused to wear 
them continuously. 

"Why do so many people, especially children, wear glasses now-a- 
days"? The above question one hears frequently and the answer is sim- 
ple. It is only within relatively recent years that we have come to recog- 
nize the relation between the eyes and that group of symptoms that we 
know means eyestrain. That the eyes of the human family are being de- 
stroyed is not true. That our remote forefathers had better eyes and 
sight than we have is probably not true. That they had less trouble 
with their eyes may be true but such was the case simply because they used 
their eyes for reading much less than we do now. Fifty years ago rela- 
tive^ few children continued long in school and those who did strive for 
higher education and achieve it, in spite of severe eyestrain, had no means 
of knowing that glasses would relieve their discomforts. 

The condition that we know as appendicitis is not new and probably 
is no more common than it used to be, although our present day habits 
of life may tend to induce it. Doctors now know appendicitis when they 
see it, they know what to do for it to save life, and consequently operation 
for its cure is common. Eyestrain has existed ever since man began to 
study and so our present day habits of study tend to induce eyestrain. 
Doctors now-a-days recognize eyestrain by the symptoms that were for- 
merly thought to have no relation to the eyes. The means for relief is well 
known and consequently glass wearing is common. If we make the best 
possible use of what positive knowledge we now possess concerning the 
preservation of eyesight, the generations to come will enjoy more com- 
fortable and efficient eyesight than any of the generations that have past. 

CHAPTER V 

THE SCHOOL INSPECTION 

Outline and Record. — For the guidance of those who are not familiar 
with the symptoms of disease in the eyes and ears the outline found on 
page 24 has been prepared. 

It is thought to be particularly well adapted to the use of teachers 
who are to carry out eye and ear inspections in public schools. 

The inspector should first familiarize himself with the questions 
in the outline and gain as clear an idea as possible of their significance. 

Very few of the questions will actually be put to the pupil. The 
teacher who is a keen observer will soon be able to record answers to prac- 



SIGHT AND HEARING OF SCHOOL CHILDREN 23 

Public School[s] of , Missouri 

MEDICAL INSPECTION 



Record of.„ ..._De 



School Grade._ Age._ Sex._ M....F.... 

EYES. Evidences of eye disease or of 

refractive error. 

Right 

Vision 



Color Vision. 



EARS. Evidences of ear disease. 

Right feet. 

Hearing 

Left feet. 

( Aloud. 
Acoumeter Voice, j 

I Whisper. 



NOSE AND THROAT 



Card of warning to parents. 

Eye Ear Nose Throat General 



INSPECTOR 



24 UNIVERSITY OF MISSOURI BULLETIN 

tically all the questions merely as the result of his observation of pupils 
in his charge. 

Children are particularly susceptible to suggestion and it is important 
that they be allowed to tell their discomforts in their own way. Much 
direct questioning as to definite symptoms may lead the inspector into 
error and confusion. 

The inspection outline should be used in connection with a suitable 
record blank. Such a blank form is shown on page 23. This form has 
been in use long enough to prove its usefulness. As will be seen, the form 
is divided into five general sections. The first is devoted to the general 
information for identification of the pupil. The eye section follows with 
a place for recording the state of vision, and, to the right of that, space in 
which any evidence of disease or eyestrain may be recorded. In the next 
section the printed form shows a place in which the state of hearing maj r 
be recorded in terms of feet at which the whispered or loud voice may be 
heard. It is intended that a check should be made opposite the word 
"whisper" or "aloud" to indicate which tone was used in making the test. 
If Politzer's acoumeter or the audiometer of McCollie are used, plenty of 
space is available for recording the findings. The right hand half of the 
section is intended for use in noting evidences of ear disease other than 
deafness. 

The blank section for nose and throat findings has been found most 
satisfactory by the writer. Some inspectors prefer to have the names of 
the common nose and throat affections printed in the space and then 
check them as they are found at the inspection. 

At the bottom the words under "Card of Warning to Parents" should 
be encircled to indicate the organ or organs on account of which a card 
of warning must be sent. The blank form from which the one here shown 
was copied was made exactly 6" x 8" so that when folded it could be 
easily filed with other school records that were 4" x 6" in size. 

Inspection Outline for the Use of Teachers in Public Schools: 
Section I. 

A. Does the pupil have: — 

1. Stys? 

2. Red lid edges? 

3. Red eyeballs? 

4. Discharge from eyes? 

0. Excessive tearing? 

6. Bran like accumulations in the eye lashes? 

7. Crossed eyes? 

B. Does the pupil: — 

1. Hold his reading matter close to the eyes, i. e., closer than 

fourteen inches? 

2. Have any difficulty in seeing clearly across a large room 

(twenty feet)? 

3. Hold his head in an unnatural position while reading? 

4. Dread the bright light of day? 



SIGHT AND HEARING OF SCHOOL CHILDREN 25 

C. Does the pupil complain of: — 

1. Headache or browache? 

2. Feeling of sand, itching or burning in eyes? 

3. Drowsiness? 

4. Blurring of print? 

5. Tired eyes after little reading? 

6. Any other symptom of eyestrain? 

D. Does the pupil wear glasses? 

1. Are the glasses level before the eyes? 

2. Does each eye look through the center of the lens that is 

held before it? 

3. Are the glasses so placed on the nose that the pupil 

cannot see over them in looking at a distance? 

E. What is the state of vision: 

(1). Without glasses? 
(2.) With glasses? 

F. Does the pupil readily and accurately recognize and differentiate 

pure colors such as red and green? 
Section II. 

1. Does the pupil have difficulty in hearing the ordinary whis- 

pered voice across a large room (twenty feet)? 

2. Is there any tenderness about the ears of which the pupil 

makes voluntary complaint? 

3. Does he have earache? 

4. Is there any evidence of discharge from, or ulceration of, 

the ear canal? 

5. Is there any offensive odor about the head, the source of 

which is not apparent? 

6. What is the state of hearing? 
Section III. 

1. Does the pupil have the "snuffles"? 

2. Does he breathe through his mouth habitually? 

3. Is the voice abnormal in any way? 

4. Does he ' ' take cold ' ' easily? 

5. Does he have enlarged glands in the neck? 

6. Does he have sore throat often? 

7. Does he show any of the evidences of nasal obstruction? 
Section IV. 

1. Is there dullness mentally that has no apparent cause? 

2. Does the pupil have difficulty in concentrating his attention 

upon his studies? 
Types and Times of Inspections. — The regular routine physical exami- 
nation of school children should be required by law. Twenty states 
have made school inspections possible by legislative enactment. While 
all states should have laws covering this matter it is obvious that lack of 
state law need not necessarily prevent any school community from 
establishing that scheme of inspection best suited for its purposes. 



26 UNIVERSITY OF MISSOURI BULLETIN 

The ideal organization for medical inspections is that in use in certain 
of the larger cities of this country. Physicians with training that especi- 
ally fits them for the work are employed to make daily inspections of a 
limited number of children. Such a plan makes it possible promptly 
to exclude children who suffer from communicable diseases. The physical 
abnormalities that handicap a child in his school work are also discovered 
early and called to the attention of parents. A very good modification 
of this plan is that by which the daily inspections are made by nurses 
whose work is supervised and augmented by physicians at frequent inter- 
vals. There should be one school nurse for every 1000 of the school en- 
rollment. 

Both of the plans mentioned above contemplate the complete inspec- 
tion of the school child. The problem discussed in this bulletin concerns 
particularly the inspection of the organs of sight and hearing and the work 
of such inspection does not necessarily require more knowledge for its 
successful accomplishment than is herein set forth. In some communi- 
ties an arrangement is made by which a local physician makes an annual 
inspection. The value of such a plan depends upon the intelligence and 
thoroughness with which the inspection is carried out. Naturally much 
depends upon the discrimination of School Boards in the selection of in- 
spectors. The opportunity for error is so great that the plan is mentioned 
here simply to condemn it. 

When the services of a competent physician are not available the 
usually already overworked teacher must make the inspection. For- 
tunately, the eyes and ears of pupils may be investigated by the average 
teacher without any previous experience with such matters, if some in- 
spection outline similar to the one here suggested is adopted. Such in- 
vestigations will elicit much valuable information and result in untold 
good to pupils, if the cards of warning can be made to bring forth the 
reaction in parents that they are intended to stimulate. 

It is very easy to calculate that every teacher can make the sum total 
of his teaching task much easier provided he makes proper use of the 
information gained by any good routine inspection of the eyes and ears. 
The child who has less than normal eyesight or hearing will inevitably 
require much individual attention from the teacher, more attention by 
far in point of time expended than could possibly be used in a routine 
inspection of eyes and ears. It is plain that a child with lessened hearing 
in such degree as to interfere with plain and distinct articulation will 
absorb more than his fair quota of the teacher's time and energy and will 
therefore lower in some degree the quality of the class room work of that 
teacher. Multiply the one example by the amount of ten per cent or fif- 
teen per cent of the whole class and the extra burden borne by the teacher 
is seen to be enormously in excess of that created by the obligation to make 
a few routine inspections a year. Each inspection develops its quota of 
pupils needing medical attention. With that attention forthcoming, 
the amount of extraordinary teaching effort is lessened and the efforts 
expended in inspections are justified. All this of course takes no account 



SIGHT AND HEARING OF SCHOOL CHILDREN 27 

of the invaluable benefits that accrue to pupils by reason of the early 
correction and indeed cure of small defects which, if alloAved to persist, 
might forever lessen the child's usefulness. The problem is plainly and 
simply 6ne in preventive medicine and the circumstances as they exist 
justify all the attention of physicians, schoolboards, and teachers that can 
possibly be centered on them. 

It appears that the teacher in carrying out medical, or better, phys- 
ical examinations would better confine his attention chiefly to the condi- 
tions of the eyes and ears, as to detailed investigation, and let the rest 
of his general survey take account only of the gross general conditions 
that are obviously effective in limiting the child's ability to profit by his 
residence in school. If a child is in need of the services of a dentist that 
should be noted and reported. The teacher should avoid the error of 
attempting to go so far into inspection work as to make diagnoses of con- 
ditions. The suggestion to parents that there is eye or throat or ear 
trouble that is hindering a child's progress in school is usually sufficient. 
Any teacher can give correct information to parents as to the desirability 
of having immediate medical attention for a pupil who is an habitual 
mouth breather. The card of warning will accomplish that much and the 
physician will give advice as to the measures necessary to insure against 
a continuance of mouth breathing. 

The outline here presented for the use of teachers purposely omits 
any lead which would involve the inspector in problems that would be 
difficult either as to the formation of proper judgments, or the execution 
of the technic of inspection. 

Eye and ear inspection should be made : at the beginning of the school 
term; after the first six or eight weeks of school; as often thereafter as is 
reasonably possible in consideration of the demands upon the teacher's 
time. 

The inspection at the beginning of the school year gives information 
as to the existence of visual or aural defects and handicaps presumably 
previously unnoticed. The second inspection, after the lapse of six or 
eight weeks, gives opportunity to determine what deleterious effects, if 
any, have resulted from the educational process in pupils found to be nor- 
mal at the first inspection. It also allows a check on tho parents to whom 
cards of warning were sent as a result of the finding of the first inspection. 
Inspections should be systematic and the record of them should be exact, 
uniform, permanent, and as free as possible from confusing technical 
terms. 

The inspections should be carried on in a well lighted room having 
one dimension at least of twenty feet in the clear. The room must be so 
lighted as to make possible good illumination of a test chart of letters. 
The room must be quiet and isolated so that one pupil may be examined 
at a time. The examiner should have an assistant, if possible, to inscribe 
the findings as they are determined by the examiner. The findings should 
be recorded upon individual blanks provided for the purpose. 



28 UNIVERSITY OF MISSOURI BULLETIN 

The Technic of Inspection. — It should be understood that the pri- 
mary purpose of such an inspection as is herein described is to call atten- 
tion to every single eye, ear, or throat factor that is capable of preventing 
a child from getting the maximum of good from his school work and to 
advise its correction. A secondary but at the same time important pur- 
pose is to exclude from the school room any pupil whose presence there is 
in any sense a menace to his fellow pupils. 

The examination of the eyes should be undertaken with two aims in 
mind. First, to determine whether or not a child suffers from inflamma- 
tory or communicable diseases of the eyelids, and second, to record the 
state of vision and make note of any evidences of the existence of 
eyestrain. 

Diffuse daylight free from the direct rays of the sun furnishes proper 
illumination for the investigation as to inflammatory lid troubles. While 
no examination can be complete without eversion of the lids, such a pro- 
cedure is not to be attempted by the teacher. Sufficient information 
for the safety and well being of all pupils can be obtained by merely look- 
ing at the eyes without touching the face of the pupil. 

Certain communicable diseases of the lids, of which pink-eye is the 
most common, are found among school children. Fortunately they all 
have some symptoms in common by which they may be recognized by any 
person who will use some care in making the observations. Redness of 
the eyes, excessive tearing, stringy or creamy discharge, and dread of light 
are common to all the acute lid infections. The existence of such symp- 
toms is strong enough presumptive evidence to cause the teacher to ex- 
clude from school any pupil who exhibits them. 

Facts that have been recently gathered tend to show that the disease 
trachoma or true granulated lids is generally prevalent in Missouri. This 
disease is very apt to destroy vision entirely, it is hard to cure, and may 
resist treatment for years. It exists in two general types, active and inac- 
tive. The later type is usually only a latent stage of the disease and it 
may become active at any time. In the active stage the disease is easily 
communicated by the discharges, it is even conditionally contagious in 
the inactive stage. The symptoms previously mentioned are usually 
found in the contagious state of the disease. 

Trachoma is always a menace to the sight of its possessor and a con- 
stant danger to those who live in its presence. The disease should be con- 
tinually treated until it is cured. No confusion should exist because of 
the unfortunate promiscuous use of the words granulated lids in connection 
with certain eye conditions not trachomatous. The linings of the lids 
may look rough and granular and yet be free from real trachoma. More- 
over the accumulation on the edges of the lids of granular masses, referred 
to elsewhere as branlike scales, should not be called granulations. Such 
a condition is in no sense an indication of trachoma. Unfortunately 
some physicians are careless about the use of the term granulated lids, 
and the term should be used only in referring to trachoma. In matters 
of school hygiene no carelessness should be tolerated in naming inflamma- 



SIGHT AND HEARING OF SCHOOL CHILDREN 



29 



TEST FOR COLOR BLINDNESS. 




FIG. 5 



o 

E 


1 


F P 


2 


T O Z 


3 


L P "i D 


4 


* p e"c"f d 


5 


-ED P*<S Z P 


6 

7 


* rsLOPZO 


• CBFPOTEO 


8 
9 


««»nroD*oa 


•••sin 


10 


<£."• 


11 



=®5Green 



=S*Red 



VISION CHART FOR SCHOOLS 

OBI BBMM200 

JD Jm J 100 

T 3 z n 7 o 

DP m L 3 so 
L F 3 PC U 40 

C Id L 3 T F n 30 

FFiTF3ouD3 20 



FIG. 6 



«fl 



1=1 .Jp 


+ £ X 


n i * 


* *V a 


k **w * 


* t >' s21 <H x 


/ e » *» ». » 



FIG. 7 

Types of Test Charts for the Eyes. (ACknowled; 
Company of Chicago for their kindness in furnishing 
productions were made.) 



FIG. S 

;ment is due to the F. A. Hardy 
the plates from which these re- 



30 UNIVERSITY OP MISSOURI BULLETIN 

tory lid conditions. Many times the determination of the existence of 
trachoma is difficult and can be made only by an expert in diseases of the 
eyes. 

Following exclusion from school on account of redness, tearing, or 
discharge from the eyes, return should be permitted only on presentation 
of a physician's certificate that no communicable disease exists. 

Next in order should come the record of the seeing power or state of 
vision. This is best determined by means of the Snellen Test Chart or 
some of its modifications. It should be noted that Test Charts should 
be hidden from view except during tests, lest pupils familiarize themselves 
with the letters and thus consciously or unconsciously deceive the exami- 
ner. To the end that no memorizing of the charts may occur during the 
tests it is well to have an assortment of charts. 

Figure 6 shows the Allport modification of the Snellen Chart. This 
chart is especially useful for school inspections for the reason that each 
chart has attached to it full directions for its use and also useful informa- 
tion concerning the making of records and cards of warning. The chart 
shown in Figure 7 has the advantage of combining test letters with a test 
of color vision. Underneath the fine of letters marked 6 is a heavy solid 
green line, and under the line marked 8 is a solid red line. The inspector 
asks the pupil to read the letters above the red line or below the green 
fine and in that way proves his ability to recognize colors as well as the 
letters. 

Figure 8 shows a chart for the use of illiterates. The child in the first 
grade may not be familiar with the alphabet. He can call the names of 
the objects in the lines and thereby make possible a record of the state of 
vision. Accurate recording of the state of vision of first grade pupils 
is difficult. 

Test charts should be made of heavy card board and should be free 
from gloss. In all charts one line is designated as the standard or normal 
line. It should be seen by a single unaided eye at a distance of twenty 
feet when tested under the conditions mentioned below. At the end of 
the normal line in Figure 6 will be seen the figure 20 which indicates that 
the line should be seen by the normal eye at twenty feet. All the other 
lines are marked in the same terms. The so-called normal or standard 
fine may or may not be the bottom line on the test card. However that 
may be, the lines above the normal fine are so constructed as to be seen 
at increasing distances. If any lines of letters appear on the chart below 
the normal fine they are intended to be seen by the standard eye at a dis- 
tance of less than twenty feet. 

The recording of the state of vision is accomplished then as follows: 

The test chart must hang in good daylight, twenty feet away from the 
pupil, with the normal line of letters on a level slightly below that of the 
child's eyes as he stands or sits while under test. The source of light 
must be behind and to the side of the pupil and never in a place to allow 
direct or troublesome cross fights to enter the eyes under test. Direct 
sunlight must be excluded from the region in which the test chart hangs. 



SIGHT AND HEARING OF SCHOOL CHILDREN 31 

Children who ordinarily wear glasses should have a record of vision first 
without glasses and then with glasses. One eye is lightly covered, and 
never pressed upon, by a card of sufficient size to exclude effectually all 
use of the eye under cover and at the same time to throw no shade over 
the eye under test. In covering one eye and then the other for the pur- 
pose of testing and recording the state of vision, it is well for the examiner to 
observe a fixed custom of always testing first either the right or left eye, — 
it matters not which one so long as the practice is uniform with all pupils. 
With one eye covered as indicated, the pupil is asked to read the chart 
from the top down, saying clearly the letters as he sees them in each line. 
The pupil should be cautioned to read carefully and slowly if he shows 
any tendency toward inaccuracy. It often happens that the pupil will 
cease reading before the normal line is reached, in which case he should 
be encouraged to "try the next line", and the next and the next and so 
on until the examiner is positive that the pupil has actually read the small- 
est line that he possibly can. The record should show the smallest fine 
that can be read by any possibility, not the one that can be easily seen. 

If it so happens that the pupil reads the normal or standard line with 
the right eye, for example, the record should show that the vision in the 
right eye equals 20 / 20 which simply means that the right eye sees at a 
distance of twenty feet the line that a normal eye should see at that dis- 
tance. The vision then is normal. If by chance the eye under test sees 
a fine smaller than the standard, the examiner will note the number at 
the end of the line. If the line happens to be the one that should be read at 
fifteen feet, then the state of vision is recorded as 20 / 15 which means 
that the eye under test sees at twenty feet that line which the standard 
eye should see at fifteen feet. In other words the record of the state of 
vision is made in the form of a fraction the numerator of which always 
indicates the number of feet between the test chart and the eye under 
test. The denominator of the recording fraction indicates the distance 
in feet at which the normal eye should see the line of letters which has 
been found to be the smallest possible one that can be read by the eye un- 
der test. 

For example, if the eye under test sees only the line of large letters 
at the top of a chart and the normal eye should see that line at two hundred 
feet, the record would show the vision in the eye under test to be 20 /200. 
The recording of the state of vision in the form of fractions is used merely 
as a convenience and is an almost universal practice among oculists. 
Sometimes this record is made in terms of meters instead of feet. It 
should not be assumed that the fractions recorded are reducible in comput- 
ing the quantity of vision and that the record 20/200 vision, for instance, 
means that an eye so recorded has 1 / 10 the power of the normal eye. 
In case the pupil reads the normal line correctly except one or two letters, 
the vision may be recorded as 20/20 minus. If on the other hand, he 
reads the normal line or any other line, and a few letters in the one below 
it, the record may be made to show that by adding the plus sign after 
the recording fraction. 



32 UNIVERSITY OF MISSOURI BULLETIN 

In determining the state of vision for the second eye the procedure 
should be the same as for the first one. Teachers are advised against the 
use of the astigmatic charts or dials in school inspections. No really use- 
ful information will be gained and much time will be wasted in efforts 
to use them. Due consideration should be given to all the suggestions 
in the inspection outline. When the abnormal conditions there suggested 
are found to be present, they should be noted in the proper place on the 
inspection record. 

In answering the question "P 1 " in Section I of the Inspection Outline 
the purpose is to determine the presence or absence of color blindness. One 
of the simplest means of settling the question as to color blindness is to 
make use of the Rumble Test, apparatus for the making of which is shown 
in Figure 5. The colors are shown by transmitted light and the card is 
so arranged as to discourage subjectivity or simulation on the part of the 
pupil. Full directions for its use accompany each chart. 

No conclusions as to the nature of the eye defect should be attempted 
merely as a result of the finding of the state of vision. The vision of one 
child may be 20 / 20 or even 20 / 13 in the presence of violent symptoms 
of eyestrain due to farsightedness. The identical kind and degree of error 
in another child may reduce the vision to 20/30 or even more without 
producing a single painful symptom. 

There is very little in the mere appearance of eyes to lead one to a 
correct determination of their refractive condition. Eyes that cross 
inward or toward the nose are usually farsighted. Those that cross out- 
ward or toward the temples, are usually nearsighted. In crossed eyes, 
the myopia or hyperopia is usually not equal in the two eyes. Persons 
who squint are usually nearsighted. Those who hold reading close to 
the eyes are usually nearsighted, but they may be highly farsighted. In 
high farsightedness, nearsightedness, and astigmatism, the distance see- 
ing power is lowered in direct proportion to the amount of refractive 
error. 

The possession of good sight is by no means an evidence of normal 
eyes. There is nothing about a moderate degree of farsightedness to 
preclude the possession of most acute vision for distance seeing. Many 
an individual "sees well" who suffers intense eyestrain. Forty percent of 
people who need and wear glasses for relief of eyestrain can see normally 
in the distance without glasses. They make use of glasses not that they 
may "see better" but that they may see in comfort, i. e. without the 
development of eyestrain. 

Glasses do not cure refractive errors in the sense of causing them to 
disappear or grow less in degree. Properly fitting glasses do cause the 
symptoms of eyes train to disappear and they do also tend to check the 
progress of nearsightedness. 

It should be the universal practice to send a card of warning in the 
case of children with less than normal vision in one or both eyes whether 
symptoms of eyestrain are present or not. With the evidence of* eye- 



SIGHT AND HEARING OF SCHOOL CHILDREN 33 

strain at hand, the card of warning must be sent whether the vision is 
normal or not. 

The eye condition having been investigated one next proceeds to the 
inspection of the ears. 

Tests of hearing are carried out more or less roughly in inspections 
by teachers. The results are very satisfactory if proper heed be taken of 
any indications of faulty function. For purposes of inspection of the 
ears by teachers, the human voice may best be used as the test sound. 
The ordinary speaking voice of the examiner as produced after an ordinary 
expiration, i. e. when only the residual air remains in the lungs, is a good 
and fairly constant test tone. Under the condition of testing here pre- 
sumed, it is sufficient that the record state whether the pupil can or cannot 
hear whispered words, numbers, and short sentences with a single ear 
across a large, quiet schoolroom. The normal ear hears whispered speech 
at a distance of fifty feet in a still room. 

During the test the pupil should stand facing away from the examiner 
and should have one finger pressed tightly into the ear not under test. 
In this position he should repeat after the examiner the words, numbers, or 
phrases spoken by the examiner. It is very important that the child 
shall not see the movement of the inspector's lips during ear tests. 

The loss of a noticeable amount of hearing is not proof positive of 
serious ear disease, but in this instance as well as others here considered, 
prompt and efficient attention during earty school life may overcome the 
beginnings of what might develop into a serious obstacle to progress in 
school and business. 

Small degrees of deafness are sometimes serious to children. The 
hearing is a great aid in the development of fluent and accurate speaking 
in the sense of ordinary conversation and the loss of acute hearing handi- 
caps the young pupil in proportion to the degree of deafness. Any dis- 
charge from the ear canal, be it scanty or profuse, demands the immediate 
attention of an aurist or family physician. The presence of ear discharge 
may be discovered in searching for the source of an unpleasant odor com- 
ing from the person of a pupil. Most foul smelling ear discharges indicate 
the existence of serious ear disease. 

The card of warning will be forthcoming of course in case affirmative 
reply can be made to any one of the first four questions in Section II of 
the Outline. If the hearing is lowered that fact must surely be reported 
in a card of warning. 

Concerning the condition of the nose and throat, no information 
need be recorded by the teacher except that elicited by attention to the 
questions under the heading Section III in the Outline. Intelligent re- 
plies to the seven questions will in the majority of cases give sufficient 
evidence to warrant the card of warning if it should be sent at all. It is 
not to be expected that the teacher shall give an opinion as to the normal 
or diseased condition of a throat as the result of its direct inspection. Such 



34 UNIVERSITY OF MISSOURI BULLETIN 

determinations are plainly the duty of the physician or other specially 
trained person. 

From the standpoint of the teacher the paramount factor in the in- 
spection of the nose and throat is to determine if possible whether there 
exists in these regions enlarged, obstructive, or diseased adenoid 
tissue. Attention to the questions in the Outline will help greatly in the 
determination. 

The Card of Warning. — The wording of the card of warning will vary 
with the type of inspection that has been conducted. 

For the school superintendent it is sufficient in addressing a parent 
to say that the school inspection shows some apparent eye, ear, or throat 
trouble, as the case may be, and further that he, the parent, is urged to 
have immediate council with the family doctor, the oculist, or the aurist 
as the needs indicate. It is useless to insist upon the council with an ocu- 
list in a small community where no such specialist resides. Here the pupil 
must be referred to the family doctor and he must determine whether the 
pupil can be cured at his hands or must seek an oculist or aurist. Care 
must be used to the end that the ignorant layman may be helped as much 
as possible to differentiate good from unworthy physicians. Too much 
confusion exists in many quarters concerning the terms oculist and op- 
tician. The card of warning should not confuse those terms. 

A child who refuses the regular inspection and declines to submit 
to it ought to be excluded from the benefits of the public schoolroom until 
he will submit. With the very young, the tests can be carried on much 
as if they were games. 



REFERENCES FOR FURTHER READING 

Allen, William H., Civics and Health. 

Coler, George W T ., Teeth, Tonsils and Adenoids. Note: This little 

booklet can be secured free of charge upon appli- 
cation to the Home Office of the Metropolitan 
Life Insurance Company, 1 Madison Ave., New 
York City. 

Cornell, Walter S., Health and Medical Inspection of School Children. 

Gould, George M., Biographic Clinics, Vols. 1 to 5. 

Norris and Oliver, System of Diseases of the Eye, Vol. 2. 

Reick, Henry O., Safeguarding the Special Senses. 



Preventive Medicine 

The University of Missouri 
has established, in connection 
with theDepartment of Prevent- 
ive Medicine, a bureau of in- 
formation. This office will 
upon request furnish to the 
citizens of Missouri practical 
information regarding the pre- 
vention of disease. A labora- 
tory is also provided to make 
the necessary examinations. 
The service of the bureau and, 
as far as practicable, those of 
the laboratory are free of 
charge. For further informa- 
tion, address Preventive Med- 
icine, University of Missouri, 
Columbia, Mo. 



THE 

UNIVERSITY OF MISSOURI 

BULLETIN 

Volume 15 Number 3 

Issued Three Times Monthly 

MEDICAL SERIES 

EDITED BY 

D. H. DOLLEY 

Professor of. Pathology and Bacteriology 

.5. The Relation of Sight and Hearing to Early School Life, by Guy L. 
Noyes, Acting Dean of the Faculty of Medicine and Formerly Pro- 
fessor of Diseases of the Eye and Ear. 

To Be Issued: 

The Prevention of Tuberculosis, by 0. W. H. Mitchell, Associate Professor 

of Pathology and Bacteriology. 
Water — the Prevention of its Pollution, by O. W. H. Mitchell, Associate 

Professor of Pathology and Bacteriology. 
Natural Old Age and Natural Death, by D. H. Dolley. Professor of Pathol- 
_ ogy and Bacteriology. 

Copies of the University of Missouri Bulletin, Medical Series, will 1 f 
furnished free until the edition is exhausted. Those who desire the en- 
tire series may have their names placed on the permanent mailing list 
upon request to the Department of Preventive Medicine, University of 
Missouri, Columbia. 



Entered as second-class matter at the post office at Columbia, Missouri. 5000 



yBRARY OF CONGRESS 

• 



019 736 338 1 



